Percutaneous Needle Tenotomy of the Plantar Fascia
Plantar fasciitis is one of the most common reasons patients seek orthopaedic care for the foot. The plantar fascia is a tendon-like structure located on the sole of the foot that helps to support the arch. The plantar fascia in constructed like an electrical cable with thousands of individual fibers woven together. Excessive loading or stretching of this tissue produces small microtears particularly where the fascia meets the calcaneus. These microtears heal with scar tissue which doesn’t have the same strength and elasticity as healthy tissue and as the excessive loading continues, more microtears occur and after a time, there develops a large amount of unhealthy, degenerative tissue that becomes painful and difficult to treat.
Plantar fasciitis also occurs due to physical activities that stress the fascia, including sports, vigorous exercise, or in people who have to stand on their feet all day. Improper shoes can cause the problem if they do not provide enough arch support, heel cushion, or flexibility.
There is usually intense heel pain on taking the first morning step or after getting up after sitting for awhile such as taking a ride in a car. This pain subsides as the patient begins to walk around, but it may return later in the day. If symptoms occur gradually, a chronic form of heel pain causes patients to shorten their stride while running or walking. Patients also may shift the weight toward the toes, away from the heel.
Plantar fasciitis can be diagnosed based on the history and physical examination. If the diagnosis is still in doubt, your doctor may order x-rays, perform a musculoskeletal ultrasound at the time of your visit or consider an MRI scan if a stress fracture of the heel bone is a consideration. Ultrasound can measure the thickness of the fascia which has been shown to correlate with heel pain and detect small bony irregularities where the fascia attaches to the bone.
Once someone gets plantar fasciitis, it takes a long, long, time to go away and most people get better if they stick to an aggressive stretching program as the Achilles tendon and calf muscles are often very tight and hold the plantar fascia “hostage” by restricting motion in the foot and ankle.
Treatment Options include the following:
• Stretching exercises to lengthen the heel cord and plantar fascia
• Ice massage to the sole of the foot after activities that trigger heel pain
• Activity modification that substitutes other activities for running or jumping
• Proper shoewear
• Taping the sole of the injured foot
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
• Physical therapy using electrical stimulation with corticosteroids or massage techniques
• A short period of immobilization in a boot or cast.
In patients who fail all these measures, surgery is sometimes performed. Surgery is often not effective which is why a good orthopaedic surgeon, especially one that specialty training (fellowship trained) is reluctant to operate.
At Beacon Orthopaedics we offer a newer technique that our patients have found very successful. Percutaneous needle tenotomy (PNT) is a technique where a small gauge needle is introduced through the skin into the fascia under ultrasound guidance to insure precise placement of needle into the scar tissue to break it up and release part of it from the bone. This is also known as Ultrasound Guided Plantar Fascial Release. A recent study (J Am Podiatry Med Assoc 99(3): 183-190, 2009) evaluated the safety and effectiveness of ultrasound-guided plantar fascia release for treatment of chronic plantar fasciitis. 41 patients were studied and over 80% had a tremendous decrease in their pain that allowed return to normal daily and athletic activities.
Usually a nerve block to the lower leg or ankle is utilized to produce regional anesthesia. Under precise ultrasound guided needle placement, the needle is used to poke several small holes in the fascia. This part of the procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. This stimulates blood to circulate into this area as scar tissue does not have a good blood supply. Often this relieves the pain to the point where the patient can stretch without pain thereby keeping the pain from returning. An additional option is to also utilize platelet rich plasma (PRP), obtained from a sample of the patient's whole blood which is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. This allows the unhealthy tissue to heal with healthy tissue that helps the pain from coming back if the patient continues to stretch and wear proper shoes. PRP does not produce any instant pain relief and does take a number of weeks to fully relieve the pain. To learn more about the benefits of PRP, click here.
Below is an ultrasound imaging showing a PNT of the plantar fascia. The calcaneus (heel bone) is shown as is the thickened plantar fascia attached to it. Note the osteophyte to which scar tissue is attached. The needle will be used to release the scar tissue and the osteophyte helping to relieve the pain. Once loosened, the osteophyte becomes inert and does not cause any pain.
Click here for a list of frequently asked questions about PNT